Professor Christopher Nordin, AO, who is Visiting Professor at the University of Adelaide and a consultant physician at the Royal Adelaide Hospital, discusses the influence the pharmaceutical industry has on doctors’ prescribing habits.

Transcript
This transcript was typed from a recording of the program. The ABC cannot guarantee its complete accuracy because of the possibility of mishearing and occasional difficulty in identifying speakers.

Robyn Williams: I wonder if you’re like me, a rather recalcitrant patient. My desk drawer has a collection of prescriptions, never used, because I try to do without drugs whenever they strike me as marginal. Put it another way: the shadow of the law hangs over doctors who say, ‘No, you’ll be fine in a couple of days, don’t take anything. Just go for a walk, have a rest’, or whatever.

If something goes wrong, could the doctor be liable? Is it usual to prescribe drugs, one or two, or three, just in case?

The pharmaceutical benefits cost this country $6-billion a year. A large amount when you consider the shambles some States’ hospitals are in, think New South Wales!

Why then, so many prescriptions? Well Professor Christopher Nordin in Adelaide has a firm view, and it’s a worrying one. He’s been at the Adelaide Hospital and the Institute of Medical and Veterinary Sciences there for many years, though he wants you to know that his position is a personal one, and doesn’t necessarily represent his university on this issue. He has treated osteoporosis for 50 years, and has talked about on this program before. Today though, it’s drugs.

Professor Nordin.

Christopher Nordin: It is about a hundred years since that great Canadian-born physician Sir William Osler, Regius Professor of Medicine in Oxford, complained about the increasing influence of the pharmaceutical industry on the medical profession. If he knew how this influence had increased since then, he would be turning in his grave at the way the industry now dominates doctors’ prescribing habits. It does this not only by direct and indirect pressure on the doctors themselves, but also by encouraging the public to ask for scripts and to demand that governments provide the money. I recognise, of course, that the pharmaceuticals I have in mind must be effective and useful, or they would not have been approved by the Therapeutic Goods Administration or listed in the Pharmaceutical Benefits Schedule, but that doesn’t mean that they should be over-prescribed. Is an expensive treatment really necessary in every patient that receives it? Is there perhaps a cheaper alternative that would meet the needs of the particular case? Is the recommended dose the necessary does? It is here in this grey area that the industry’s considerable influence is felt. In my own field of osteoporosis, there is no doubt that certain expensive remedies are being over-prescribed. The same is almost certainly true in other fields of medicine. Over-prescribing makes a major contribution to the $6-billion now being spent on Pharmaceutical Benefits in Australia.

How is it done? Well the immediate pressure on the medical profession comes from the travelling reps who seek and obtain regular interviews with General Practitioners and specialists. At these sessions, representatives talk up, and provide reprints on published industry-sponsored Randomised Control Trials (known as RCTs) which have become the gold standard in assessing the value of pharmaceuticals. These trials, often international in scope and running to thousands of cases and controls, are often financed so generously that the funding places the investigator under an obligation. I have myself held several small grants from pharmaceutical companies and am aware that this has influenced my prescribing habits and my freedom to speak out. I recall the relief I felt at a meeting in Melbourne some years ago when I realised that I could speak freely about the products of a particular company because the grant I had received from that company had just expired. How much more obligated must doctors feel who accept positions on advisory boards or act as consultants to industry. How can such positions fail to influence their prescribing habits, and even the advice they give when consulted about the merits of a particular drug? How can advice given by consumer groups to the authorities be impartial when these consumer groups are themselves largely or wholly financed by the pharmaceutical industry?

Another inducement is the prospect of a future publication to add to our C.V. The publication usually appears in a very reputable journal after peer review, but it is hard to believe that the sponsors do not exert some influence on the presentation of the raw data. In fact, Richard Smith, respected editor of the British Medical Journal for many years, has said that studies funded by industry are subtly manipulated to give positive results and are four times more likely to have positive results than those funded by other sources.

In Australia, the most important pharmaceutical decisions are made by the Therapeutic Goods Administration, the TGA, and the Pharmaceutical Benefits Advisory Committee, the PBAC. The PBAC is under constant pressure from the pharmaceutical industry to subsidise expensive new preparations and when it seeks outside advice, the advisers are likely to be receiving support from one or other of the companies sponsoring the application. This is one way that the industry can influence these committees. The pressure will increase under a cost recovery program designed to make industry pay for the cost of processing their submissions. This is called ‘user pays’ and has the effect of making a public body financially dependent on the industry it is supposed to be regulating. Is the government that pushes this policy not aware that he who pays the piper calls the tune? The influence of industry on the PBAC is bound to grow as it pays an increasing proportion of the running costs.

The PBAC is also under yet another form of pressure because of the political consequences of its decisions. When it recommended last year that everyone over 70 with a low bone density should be entitled to subsidised treatment to prevent hip fractures, the news was thought to be so politically significant that it was announced by the Prime Minister himself, and presented as a triumph for the old people of Australia. But the triumph was really with the pharmaceutical industry when 250,000 elderly women in Australia were suddenly entitled to a treatment costing $500 a year to the taxpayer. Would it not be better to prevent osteoporosis cheaply in women in their 50s, rather than waiting 20 years for it to develop, and then treating it expensively in women in their 70s and 80s? But Vitamin D and Calcium attract no subsidy because they are thought to be too cheap to need it. Fifteen dollars a month may not seem much to the government, but it may be enough to prevent some pensioners from getting these natural remedies. Yet the importance of these treatments is so well-recognised that the companies concerned now provide Vitamin D and Calcium free to patients who are prescribed their products. They can afford to!

Another way in which the industry exerts pressure on doctors is by offering us a variety of professional services. In one of these services, widely advertised to GPs, a company representative shows the Practice Manager how to use a company disk to ‘trawl’ through the practice database identifying patients with problems which might be treatable with the company’s products. When that has been done, a company-sponsored nurse interviews the selected patients and draws up a management plan for the GP which, if approved by the doctor, attracts a Medicare item number. One of these companies proudly announces that over 65,000 patients were assessed in this way in 2005. What, one may ask, is a pharmaceutical company doing assessing patients? It is surprising that no government or professional body has stepped in to prevent this commercially sponsored program.

The pharmaceutical industry is also involved in Continuing Medical Education for doctors in other ways. Thus the companies organise educational sessions, with ample food and drink provided, at which the merits of their products are presented, usually by medical specialists. Some of these meetings are recognised by the College for Continuing Medical Education points, despite the likely bias in the presentations. Even educational services specifically tailored to provide Continuing Medical Education points, and organised by professional bodies like the Divisions of General Practice, may be sponsored by a pharmaceutical company, meaning that it provides the food and drink. In return for this hospitality, a company representative is allowed to present a 10-minute commercial before the meal. It is hard to understand why these professional sessions are not held in universities or hospitals with doctors paying for their own food and drink out of practice expenses, rather than in up-market hotels and restaurants where industry provides the refreshments.

And then there is the ultimate consumer, the patient. How are patients induced to ask for branded products? Well drug companies are not allowed to advertise prescription drugs directly to the public, but they can achieve the same effect in other ways. One is to sponsor on commercial television a health promotion advertisement about a common condition, such as obesity, which ends by advising those who think they are obese to consult their doctor. When they arrive in the doctor’s surgery, they are pleased to learn that a new drug to treat obesity has just appeared on the market and that the doctor will be happy to prescribe it. What a coincidence! I am reminded of the announcement from the London Influenza Bureau which warned the people of England that they were about to face a serious influenza epidemic and advised them to get themselves vaccinated. Only when an enterprising newspaper did some investigative work did it become public knowledge that the London Influenza Bureau was financed by the three companies which made the influenza vaccines!

In this talk I have tended to blame the pharmaceutical companies for their undue influence on prescribing. It could be argued, however, that they are only doing their duty to their shareholders by maximising their profits; it is as much the fault of the medical profession, some say, in allowing itself to be manipulated. I asked a lawyer whether it is the briber or the bribed who commits the offence of bribery. ‘Both’, he replied. Perhaps that sums it up.

Robyn Williams: Perhaps it does. Christopher Nordin is a visiting Professor at the University of Adelaide, and is a doctor treating osteoporosis at the Royal Adelaide Hospital. I suspect now he’ll be off the big pharma companies’ lunch list.

Curiosity, skepticism, objectivity, and the use of scientific reasoning are fundamental to the practice of medicine. These attributes should permeate the entire medical education continuum.â€
AAMC-HHMI Committee 2009

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